Dr. Deepak Talreja and Chelsea Christensen describe a pilot study that focused on early fluid detection in heart failure patients in efforts to intervene and prevent readmission after discharge.
Perfect. We got a, a big crew here over at the beach as well and thanks for Amy for coordinating broadcasts. As we look at the uh grand round schedule for the rest of this year. We've got a lot of exciting talks coming up and this is what I'm excited about. We're gonna talk about a community level of uh care for CH FA pilot. We did recently at the Virginia Beach uh hospital um in alignment with the advanced heart failure team. Uh Before I talk about that, uh I wanna uh congratulate the entire division. This last weekend was our annual cardiology conference. We had two conferences running in parallel with each other simultaneously. On the right in blue, you see the cardiology for the specialist and on the left cardiology for the primary care. Over half the division participated directly on the day of the conference. And even more if you look at um those that were available throughout um throughout the scope of this and help me with arrangements. A special shout out to uh Amy Ross and Mike Loveland and the entire media team for making this come off without a hitch. I received incredibly um positive feedback. We changed the format this year and made it a case based approach and that really added some excitement. Our keynote speaker was Dr Toby cos from the Cleveland Clinic. And in the near term for those that were away or couldn't make it or missed any of the talks that were going on, this will be available all online. And for those that attended, it was a nice bolus of CME so Amy and team, thank you for making the conference a success again. And now our minds are turning to next year's conference. But before that, let's talk some about heart failure. This is a topic that we've heard a number of tremendous talks from members within our own division recently. And my goal in the 1st 10 minutes is not to repeat all that data, but just to summarize some of what I've learned from colleagues in this arena, what we know is cardiology is a complex field. We're taking care of a lot of patients in a time of increasing shortages of staff of infrastructure nationally. If you look at what we've achieved in the world of management of coronary artery disease between aggressive guideline driven medical therapy and appropriate targeted revascularization, both percutaneous and surgical. We've seen a very significant reduction in the last 30 years in coronary deaths. Unfortunately, if you look at what's going on in the world of heart failure, the numbers in terms of patients we're taking care of is only increasing. And in fact, you could say some of this is because of the success we've had in the worlds of ep interventional non invasive imaging and structural therapy. As we've helped patients live longer with more serious comorbidities and structural heart disease. As advanced uh congenital heart failure disease has uh has gotten to where we can help patients live longer. There are more patients in the sphere of interest for heart failure. And so, unfortunately, that has, has been part of what's caused this significant increase in the burden of heart failure. We know that the economics are creating an increasing burden in the world of heart failure. These are some simple numbers. You can find many but they're all in the same ranges greater than 1.1 million hospitalisations for heart failure. The average length of stay being five days and especially as patients get sicker, frailer and older, that number is only going to increase more than 3 million hospitalizations in the United States that include heart failure as a significant contributor, about 25% all cause readmission within 30 days and 50% within six months. So these sick patients, we can often get them on track. But through a combination of limited therapies of limited compliance, limited follow up that leads to this and not only is this a tough situation now, but by 2030 there's projected to be a twofold increase from 2013 with a $70 billion increase in spend. And in the world of heart failure therapy, we know that 50% of costs are attributed to the hospitalization itself. So this is a morbid process and it's extremely expensive to the health care system. Getting back to morbidity. We know that as patients start getting hospitalized increasingly for heart failure, there's this spiral that tends downward to ultimate death. So keeping them out of the hospital is key in the United States. There's been a 27% increase in heart failure hospitalizations in the last four years for all the reasons we talked about earlier. Now, we know that heart failure, like so many parts of care are really dependent on a great team. And we're fortunate to have a team with each subspecialty represented with physicians, with nurses, with navigators, with A PPS, all collaborating together and it's across specialties as well. The heart failure specialist brings the extreme knowledge base to the table. But a lot of the care really is from their cardiologist, their primary care doctor, their nephrologist, their endocrinologist. This is really a team based sport. We have a tremendous advanced heart failure team and many of the talks including last weeks and the weeks before have been focused by that team in this area. But it's a small group of patients to be deal of providers to be dealing with this large group of patients we're talking about. And that's why everyone has to play a role in this and the old mantra, whether it's uh heart failure, whether it's structural heart disease, whether it's a FB, whether it's really any of the disease processes, we uh we deal with the hardest sickest group is that top of the iceberg. And that's where our advanced heart failure team dealing with complex CHF very low EFS genetic syndromes, infiltrative disease, transplant, and L VDs to name a few conditions really has to be able to focus their time. And so the the iceberg beneath the surface really creeps to the level of the general cardiology teams. The hospice teams, the primary care teams who really are responsible for helping and participating in this team sport. So the old days of the single clinician that can handle a disease entity have really been replaced by the crew team approach or if you're a race car driver, uh analogy fan, then the, the pit crew. And so it's really the heart failure team, which includes all the groups we've talked about that has to manage these patients. I'm not gonna dive into guidelines because this has been done already in previous talks. But we live in an era where the 2024 he ref guidelines which point out our four main pillars of therapy and then an a a number of additional therapies that can be judiciously used to help those patients who have been put on the four pillars. And then we look at the 2023 AC C expert consensus decision pathway for the management of HEF PF. And our teams are aggressively working through care paths and navigation routes to get all these patients on guideline driven medical therapy. And on top of that, to manage all the comorbid diseases, whether it's kidney disease, diabetes, sleep apnea, ep diseases, diseases of coronary artery disease, and so forth that have to be co managed. At the end of the day, you look at, you really think about all these different lenses and angles that we have to optimize to take care of these heart failure patients. So as a team, there's a lot of work ahead of us. And one of the things is basing this on increasingly accurate data. So we know that if you look at the progression of heart failure, by the time the patient is clinically congested and presenting to the hospital, we've kind of missed the boat. So if we can give ourselves that additional gain in time on blue, by picking up hemodynamic congestion, this has been an area. There's been a lot of work on in different types of devices and using scales and making these available to patients in outpatient clinics to try to address the problem before it gets to that hospitalization. One of the limitations has been that the tools we use to recognize when patients are going into heart failure are very 19th century tools often using weights using leg swelling, uh subjectively using symptom diaries. And as our teams really contract a little bit and as patient access sometimes is difficult, even when they do notice accurately symptoms, it's hard to quickly get them on the path to optimizing between a state of dehydration and fluid overload. Using diuretics judiciously and using those opportunities to optimize guideline driven medical therapy. So this whole outpatient decision making pathway has traditionally been guided by relatively inaccurate signs, symptoms and weight assessments. And to call that out in the hospital, we have uh uh diagnostics including echoes, BNPs and chest x rays. But both in the outpatient arena and when patients are at home, we have these less accurate symptoms like edema, weight gain raws JB D assess and some of which they can't. And if we look at these surrogates for volume status, we notice that the sensitivity and specificity are certainly not perfect. A two pound weight gain has a sensitivity for detection of what's going to ultimately lead to heart failure of really about 10% weight gain in two of 2%. Over 48 to 72 hours brings it up to about 20%. And if we increase the numbers, the sensitivity really doesn't increase a lot. We know that the physical exam findings we use again have very limited sensitivity and specificity. The sensitivity is often below 50% in diagnosing these patients and a lot of them aren't seen by cardiologists who necessarily have a lot of expertise in differentiating this. They're seen by primary care providers, primary teams in the outpatient setting who have a lot of other things, they have to maintain expertise in. And so the the the exam findings potentially become even less accurate. Some solutions over the last decade, we've come up with are invasive monitoring with the cardio uh system. And the uh the champion trial has been one trial that's been interesting to see results which mirror some of what we've seen locally with the potential to reduce heart failure hospitalization. By this more accurate measuring of what's going on in a patient in an outpatient status, it requires of course, intense collaboration with our outpatient teams. And so today, I'm gonna turn over the floor to Chelsea to talk about something new. We've been trying. Zole has a product and we were in partnership with them in some of the earlier trials with the life vest system and, and contributed to some of the data and indications that have come up for treating arrhythmias in high risk patients. More recently, they've come up with a heart failure management system which Chelsea is gonna talk about here. Let me turn over the floor. But quickly I'm gonna introduce Chelsea. Chelsea. Christiansen is originally from Cleveland Ohio and completed school for Physicians Assistant in Marietta College in Marietta Ohio. She's been a cardiology P A for nearly 10 years now and has been with Centa cardiology specialist since 2020. She's Officer of Tara Virginia Beach and Centa Princess and A PP team lead and more importantly, she's responsible for keeping me in line. Yeah, mostly. All right, good morning everyone. It's me. Um, I'm just gonna jump right into it and a couple of my first slides kind of overlap a little bit with, uh, what DAC was talking about. Um, when you're talking or looking at CHF readmissions, uh, national averages show that after that initial admission for CHF, one in five patients is going to be readmitted within 30 days. So that's about 20%. And then one in three patients are going to be readmitted within 90 days or about 30%. Um similar chart over there off the side where, you know, there's some of those warning signs that are coming building up as we're tipping towards that heart failure event. Um But we really focus on the weight and symptoms as we're educating patients towards the very end. Um And we're just already tipping towards an admission right there. Uh When you get towards weight and symptoms, starting to show what we do here in the hospital, like Doctor Talreja was saying, is we really talk to patients about sodium restriction, fluid restriction. We hammer on daily weights, medication compliance. There's a lot of constraints with those things as well that we're of course counting on the patients to understand that and to actually comply with that compliance is a huge thing with CHF and we don't get a lot of great compliance, which is part of the problem with it. And all of that takes a lot of extra time. Sometimes it takes extra staff, it takes an extra chf navigation team. Some of our hospitals don't even have. Um So we're relying on education that a lot of us don't have the time or staff to provide. Um And like Doctor Treo was saying something that really sticks with me. Even if I do have the time to educate patients on this stuff, half of patients that return for ach F read admission have gained an insignificant amount of weight. So we tell them to watch all these things and they can still just come right back to the hospital with really no change in their daily diaries at home that they're tracking uh which brings us to the Zole H fans or heart failure management system. This is a picture of what the device looks like. So it's a sensor kind of that white square looking thing that's on an adhesive patch. It gets stuck right under the axillary region there. Um And at the bottom, the graphic is showing you what's in the box itself when it's shipped to the patient's house. So it comes with that ad adhesive patch. Um The patient five days once a week, something like that, the sensor snaps into the adhesive patch itself. So that way the sensor can pop in and out. Um So the patient can hop in the shower or do things like that. Sensor itself snaps on the charger about once every couple of days to charge that black smartphone looking thing is called the gateway device. And it's what actually pulls the data from the sensor to ping it to the server. Um And then a good old power cord, how the device or HF MS works is that it measures TF I or thoracic fluid index, an early indicator of heart failure decompensation. TF I itself is a unit number that measures a deviation from the patient's established baseline in terms of their pulmonary fluid. So the thought here is that as a patient starts to back up on fluid, their pulmonary tissue is becoming um you know, excessively hydrated or thickened with that volume. And so the radar waves are going to take a longer time to pass through that pulmonary tissue and ping back to the device. So as a patient backs up on fluid, it slows down that radar wave and changes that reading that we're pulling. When A MS is placed on a patient, it takes the device itself takes three consecutive readings which are then established as the patient's baseline. Um So if you're familiar with CardioMEMS at all, you know, we bring people in. Um and we set a goal based on the readings that we see on their right heart cath. This is different for H VMS in the fence that it actually assigns everyone the reading of 1.0. And that's because you're putting on that patch first and it's taking those first three baseline readings and putting them in that, um, kind of in the chart at the bottom within those red dashes around 1.0 is where you want to keep them. The important thing to notice here is that means that the patient has to be dry from ach f standpoint to put the device on. If you put the device on a wet patient, it's gonna give ske skewed readings, those radar waves are gonna be off and you're gonna be chasing a baseline that isn't even accurate. That's why we've been doing this um primarily as an inpatient program, right? Because the ideal patient is someone who's been admitted, they've been diar rested for a couple of days. Um, they're at their baseline or really close to it while they're walking out the door, they're gonna get home, put this patch on. So we know they were just adequately diaries and we have the best shot of success to keep them out of the hospital that way. Um As the picture shows, we're trying to hover that person right within the uh the red dashes around the 1.00 line, those little blue dots being their daily readings. Um And you can see towards the right side where they start to trend up. Um And you have to trend for three days in a row to trigger an alert to the managing provider. So not just one popping up above that. Um But three in a row triggers that alert Zole operates an independent diagnostic testing facility or an ID TF that's monitoring this data that's received from HF MS. Um The testing facility pers provides 24 7 monitoring of the patient's data and once an alert is triggered, then it triggers an email or a phone call depending on how you have your system set up um to the ordering provider. Uh When we first started this, I was getting a phone call every day from Zole. Um for some reason, it came at 8:12 a.m. every morning. I was usually chasing Tauras around on rounds. I never answered. Um but it would go to voicemail and someone would leave me a voicemail telling me the couple patients that I needed to follow up on that day. Um We eventually transitioned and changed to emails. So now every morning I get an email from Zole. Um that is pretty generic. It just says you have a TF I alert and it prompts me to log in and see what's going on. Another example of a TF I alert down there is um you can see the blue dots are hovering a little and something I learned as well is that I wasn't trying to fight to keep people at that 1.00 line. Sometimes people trend up they hover real close to that red line. You also don't wanna risk over diarying someone putting them into an A K I or developing more hypotension and then landing them back in the hospital for that reason. Um And so I wasn't necessarily fighting to keep the blue.in a pretty little 1.00 line, but it was those ones that are really dashed kind up above where they really jumped out of range. Those are the ones that I was calling and reaching out for to check on the patient. The atriums device can also monitor other things than just TF I. So off to the right is an example of a weekly report. Um atriums can also track in addition to TF I the heart rate, respiration rates, sleep angle of your patient and activity, which is defined as just not being at rest or hours per day active. Um The system will send me this weekly report but it's not something that I get a separate alert for. So when it comes to them, reaching out to the provider, it's just for those TF I alerts or concern for volume overload that I'm getting an alert. Um weekly reports will be in the system when I get in to look if I'm um you know, being particularly nosy about a patient or want to try to answer a question I have I can get in their weekly report, but I'm not getting a weekly email on all these people to tell me a weekly report is available. It also has some ECG monitoring capability so it can send you a separate alert for any VT a greater than 150 for longer than 30 seconds, any atrial fibrillation that runs over 150 for longer than 60 seconds and a pause greater than eight seconds. What's important here is that HMS is not a substitute or replacement for an event monitor? Ok. So it's kind of bonus that it can do these type of things for you. But you know, we've all encountered a lot of patients that maybe come in with a FB RBR and they're a new heart failure and maybe they ended up getting shocked and we diara them or we have a different plan for them. Those patients might be going home with an event monitor to quantify if that um arrhythmia is gonna come back or they're burning or whatnot. Um The age a device does not do the same thing. So if you're trying to figure out how to send that patient home, yes, you could put two patches on them. Um But I think that maybe depends on the patient and if they're willing to do that. Um I did have one patient where I ran into this with where they were going home with the monitor. I came and talked to them about HFS. Um And as we talked and I realized they were gonna wear a monitor. I kind of backed off a little bit and was like, you know, maybe you have enough patches to wear. I don't put, need to put another one on you. Um But the patient was actually like, no, I I don't wanna come back to the hospital. This sounds fantastic. I will wear as many patches as you want me to. Um And I think the easy overlap too, there was that she was ok with the event monitor she was gonna wear was just for like two weeks. Um The H fans device you can wear for 90 days. So she was just gonna have a little bit of time of overlap with uh a double patch life. Um And after that, she'd be a bit down to FS. But again, HFM can give you some arrhythmia stuff but is not the same thing as a Xio vial connect, nothing like that. So who cannot get an H VS is like I mentioned earlier, anyone who's acutely volume overloaded because remember when you first put that device on, that's your baseline reading of the patient being dry. So you cannot put it on anyone who's wet. Um Anyone who's going to start dialysis within the next 90 days or a patient who currently has a device implanted that can monitor their fluid already like uh some sort of C RT D uh CardioMEMS and LVAD, something that can monitor their fluid already. You do not need to put in H FS on them as well. Um But with those exclusions that leaves so many people that's nearly anyone. Um you know, any ef any age ischemic or non ischemic, it doesn't really matter the etiology of their heart failure. Um You're really just excluding if they're about to be on dialysis in 90 days and if they have some other way of someone managing their volume. Ok. So a lot of that background was the device itself. So let's switch to how it has worked here at beach. So we started this in April. Um And obviously we're still going as of October. So we're about six months in total of 40 HP MS devices that I've ordered. 39 were approved. One got denied that was anthem. So we had just was an issue with insurance there. Um three patients were approved, the device got sent to them, they chose never to activate it and they returned it. So we had a couple that um you know, gave us a cold shoulder, but that's ok. I got over it. Um How I identified patients here. Remember those exclusions if they're just starting dialysis within the next 90 days or if they have another device that's capable of managing their volume. Um They had to be obviously admitted at Beach or CHF. Um Some of them, it was their multiple readmissions, others, it was their first time uh as an admission. He FPFFFR, patient motivation was the key driver in how I chose these people, meaning that um on rounds, you know, we're running in and out, we're trying to see a lot of people at once. Uh and it came up to the patient of who was asking when I went into the room that said, you know, why did this happen to me or how can I prevent this from happening again? Or the patient that says here are my, here is the last 90 days of what I have weighed every day. And you can see it didn't change. Why am I here? They're so frustrated that it happened in the game and they're searching for an answer or a loophole to prevent this from happening again. Um I learned that the patient asking those questions is the perfect patient for H vamps because they wanna put something on, they wanna be tracked. They want that um security blanket almost. Um to be followed up on 38 of those patients were found by me at the hospital and two of those patients were identified by the hospitalist team. Um When we first rolled out back in April, we did a talk with the hospitalist so that I could let them know I was gonna be doing this here. They were gonna see notes about it, um What it was, what it meant. Um And so we did ask the hoist team if they came across anyone they thought was good with it to reach out to me as well. So, um that was from, you know, people texting me or secure chatting me that they had a patient. So got a couple of people from that team as well. Patient profiles age range anywhere from 44 all the way up to 98. Average age was 75.5. Uh EF range all over the place, 14% all the way up to 65 varying renal function, normal kidneys through CKD four. Again, they just cannot be teetering towards dialysis within 90 days and a split of 18 female and 22 male how it worked once I identified these patients is that I needed to also learn the insurance that was um most willing to accept this. Um We avoid it as it's not currently compatible with Medicaid Self pay Tricare or Anthem. Um So part of my workflow is we're rounding these patients kind of asking the right kind of trigger questions for me that they're right for HF MS. Then I'm peeking an epic to make sure they have an insurance that'll be compatible with it. Um The beach demographic tends to be a lot of Medicare patients. Um and that you can see, I think it was what 39 I ordered. So, I mean, Medicare went through every time. Um Once I identified that patient, we're good with insurance, then I'm placing the order myself via the Z PM network. So that's a separate Zole database. It's not an epic order. It's not anything that you can find in epic but a separate Zole website that the provider has to be set up with access and ordering capability to be able to sign in log in. Create that order. Which uh I think takes me maybe less than a minute. It already has a lot of prepopulated stuff in there with my information. I just have to scroll down and enter the patients, um demographic information and their insurance info. So again, it's a pretty quick thing for me to put in. Once I order it within the Zole database, then I would reach out to our local Zole rep who's a Rachel champion. Um Rachel and I worked out a good work flow as well as we got a couple of patients in. We kind of figured out what worked and what was the best way and kind of the best use of our time to deal with these patients. So overall, I would say I did not spend a significant more amount of time um like educating patients or more time at the best. They ask those right questions during rounds or they're admitted for heart failure. And I'm kind of feeling out if it's something they would like. And then after that, I just, you know, write my notes, I run downstairs and I'm putting in the order when I to talk with the patient to do more in person education um So she would come and sit down with them, usually that day or sometimes the next day, depending on when they're going home, um to give them some handouts, uh go over what happens next, it's been ordered. And so that really kind of helped to close the loop. I think of patients really understanding what was gonna happen next. Um After all that went through and usually once I put in an order, Rachel would usually let me know within like 1015 minutes that it was approved. So it's also very quick. Um Once it was approved and we're good to go, then I added that patient to my own beach uh uh Epic tracking list so that I could keep tabs on who was getting admitted and um kind of access those patients easier through Epic once it's ordered and approved HHP MS is shipped to the patient's home. Um This I really liked as well because sometimes, you know, with life vest or other devices, the patients are sometimes stuck sitting in the hospital. Um We're talking a ton about readmission data and rates there, but also also our length of stay when it comes to CHF is a huge discussion. And so we're trying not to have these people also just sit around in the hospital waiting for something or they can go home. Um So that's also another point that I think patients like is that I've said, you know, we're gonna do this, it's gonna monitor your fluid. I'm gonna keep tabs on you this way and we're still gonna send you home today the way you want to and usually they're just like done. So just get me out of here. Um, so they're usually fine with that. Um, it gets, I think fedex to people's home uh within like 24 48 hours. So it gets there very quickly. Um, the average time from discharge to a patient activating the device, we saw it was roughly about 1 to 7 days. We would have liked, you know, to see that be closer to that one day mark because again, you want the patient to be completely di reed. So once they get home from the hospital, you hope they put that patch on pretty quick before they start to back up on fluid. But that's not always the case. Um You know, maybe they just want a break for a couple of days. Um But usually, you know, we could get up to seven days as the longest for waiting for someone to activate. Uh once they receive the device, soul calls the patient directly to instruct them how to place it and answer any questions. So kind of more backup of education that again is not coming from me, coming from someone else and they can wear that HMS device for up to 90 days and after they complete or 90 days, if they really loved it, we do have the ability to order another HP MS device and go patch on, patch on patch if you really loved it that way and do 90 days, 90 days back to back like that. Um So you can do another one even if they were already in the outpatient world, if that makes sense. Ok. Alerts. So this is how many times people or rather I was getting triggered alerts sent to me and what I did with them or how I processed them. Uh, range of alerts went anywhere from zero up to 63. Average alerts per patient is about six, but there were a ton of patients that I got zero alerts on top offenders were patients that went up from 30 32 39 or even 63 alerts. And when I say alerts, what I mean is either a phone call or an email to me about that patient. The number of times in the last six months since April that I've had to personally call a patient to tell them about, um, you know, their device triggering me. Something is, was 25 times that I reached out to people. Um The number of alerts doesn't, I'm sorry, the number of alerts does not correlate with how many times I had to call them. So you can see underneath it with someone with 30 alerts. I called them three times, someone with 32 alerts. I only had to call once someone with 39 I called eight and uh my buddy with 63 alerts, I called four times. So if you can remember earlier, I was talking about how those little dots can sometimes creep up a little bit above maybe that 1.00 line or above that red dash. But if they're hovering close to it, I'm not in a necessarily reaching out to freak out at them about their Lasix or their uh diuretic dosing. And so a lot of times I'm getting alerts and it makes me open their report and review that data, but it doesn't necessarily mean I have to call them, they might have already been starting to correct and trend down. And so I just need to eyeball it and say, uh it looks ok, I'll see if there's another alert tomorrow on them. So again, it, it maybe looks like a lot of alerts, but I'm not calling that guy 63 times. I only had to call him a couple of times. Um And then, of course, once I did reach out to someone, then I was putting in a telephone encounter. No, on epic to die um to uh show any changes in their diuretics or the regimen that I had made after the 90 days, patients can mail it back and be all done with it. Like I said, some can request if they wanna do another one, we can order another. Uh some did not complete the full 90 days and returned it sooner than 90. And I would say the biggest driver there was skin irritations. Um, we changed a little bit of our education because of this because we had a fair number of. Some people have a, like a skin reaction that actually got pretty red and angry looking. Um, so then we changed how we educated patients in the beginning where Rachel did more education with skin irritation and, you know, taking the patch off, cleaning your skin. Some people weren't doing that, um, cleaning your skin for a couple of days, letting your skin rest without the patch on. Um, and then trying to reapply the patch a few days later. Um So I think that also cut down on people returning it because of that be because we did that better education in the beginning. Um Interestingly, we have three patients that completed HF MS and have, have either already moved forward and gotten a CardioMEMS or are scheduled to have a CardioMEMS. Um I help manage the CardioMEMS program here that Taurasi implants um along with Jan Dryer and so CardioMEMS on paper seems like kind of a no brainer to us when it comes to heart failure management. But when you're trying to tell a patient who's been admitted for the first time with heart failure that you want to put an implant in them to prevent this from happening again, most of the time they think you're crazy and think I'm just gonna go home and go back to doing my normal stuff. I don't need something stuck in me like that. This is never gonna happen again is what people think. Um And so even though CardioMEMS is a great solution for this kind of a tough sell in the beginning. And so I think that am MS has become a neat kind of bridge or gap to cardio MS where patients understand, I put this patch on them and then I have to call them two times or three times in those 90 days. And like one patient said to me, you know, she was near her 90 days and I call her for a third time and she said, what am I gonna do when this patch is up in 90 days? Um You know, I'm not gonna know the fluids coming back. No one's gonna call me and I'm like, well, have you heard of something called CardioMEMS? And so it works out really well to kind of identify that patient almost kinda test the waters of who's gonna be compliant, who will answer my phone call, take their medicines the way I tell them to. Um, and then become, you know, a great CardioMEMS candidate as a result. Just some patient story highlights, um, distance to medical care is a big thing around here. I know it probably all of our center facilities. We all take care of patients from North Carolina Eastern Shore patients. Some of these patients drive a couple hours to get to, you know, a higher level of, um, hospital care or trauma care that they need. Uh, and so to fill this gap of someone that, um, normally, you know, they start to get short of breath and they're at home scared thinking. Is it time, do I need to get in the car and start driving? Do I enough time to make it over the bridge or through the tunnel to get to the hospital in a couple hours? Um, and that's a really scary thing to have to think about. Um, and so one patient, it was the patient with 60 alerts. He's way up on the eastern shore, far out of here and every time I called him, he was so grateful because to him, you know, that phone call was him not having to get in the car and drive to the, er, um, so it worked really well for patients that live farther away and don't have great access to care. Um, one of my patients, my 95 year old patient, um, he was kind of busted for self adjusting his Lasix dose based on his social schedule. Um, and so for him, I learned to call the daughter because he maybe didn't always want to talk to me. Um, but I would call the daughter and they would be in the car going up to Northern Virginia for some grandson's graduation or something. And, um, and she's like dad, did you take your Lasix Chelsea's on the phone. Um, and so, you know, he would get busted for skipping his LASIK for a couple of days and it was funny to see it reflected in HF MS right away as soon as I reached out, um, we had a good kind of subset of patients that, uh, had severe A s and were waiting TVER. So, working over here with Taraia, we see those patients a lot as kind of their TVER eval as they're working towards that procedure. Um Just over the weekend, I think, or maybe last week, we had a patient that brought in for outpatient part of their right and left, work up for TVER. Um and they were really volume overloaded. And so we admitted them, they needed a Bumex trip over the weekend and we went to discharge them yesterday. Um and we've had a few of these patients that are great candidates for HF MS because we're trying to keep them out of the hospital um while they're waiting to have their tab or done. And so that guy was really on board and excited to go home with an H FMS yesterday. Um And then just an interesting fact, we have three patients that were approved, they never activated it and returned it. All three of those patients were readmitted within 30 days for heart failure. Ok. So here's some exciting numbers that we wanted to share again, those national averages from the very beginning is that one in five patients are readmitted within 30 days. That's 20% of patients and one in three are gonna be readmitted within 90 days. About 30% over the right. The pretty green numbers show you that over here at Virginia Beach in 30 days, I had two patients get readmitted, which is about a 5.5% readmission rate and interestingly not admitted with heart failure. Um One was an Nstemi that uh needed stented. Another was ac OPD exacerbation, 90 day readmissions. We're looking at five patients total or about 14% and again, not admitted with heart failure. Uh UT I sepsis, wound infection, C diff other noncardiac issues. Um In the big picture, we're still getting uh dinged for those uh readmissions. However, it's cool that they were not admitted with heart failure. What do we do next? Um how to expand the program? And so it's worked well how we're doing things here at Virginia Beach. But um part of sharing all this info with you guys today is how to expand it to the other hospitals. Um Within the last month, we have expanded to Princess Anne and so the Beach Spa A PPS have been in the know about this since I rolled it out in April. Um we had a couple of little talks or hang out. So everybody was on the, on the same page with what I was doing, what it looked like and they were in the know if they saw a note from me or, or could see a patient that was a good person for HMS. They would let me know. Um And so they've been kind of seeing this roll out in real time. Um Jacqueline has had uh great conversations with me about this and was really excited to kind of step into this role at Princess Anne for us. Um And so Jacqueline is kind of our go to person over at Princess Anne for our HF MS program. Now, she's got six patients she's currently monitoring. Um And I greatly appreciate her. Um eventually again, the discussion is what does this look like in the future? Does it transition to outpatient management? Um You know, that I think we're all open to that discussion. It's just, it takes some finesse and it needs the right kind of nursing support and you need staff to be able to reach out to these people. Um So just all part of the discussion is what does this look like? Long term? I think an important thing to note as well is once D pac implants a CardioMEMS in someone that, you know, you're stuck monitoring that person indefinitely. Um Whereas with this population, it's constantly turning over. So it's not like the moreish fans you're writing. I mean, I guess yes, your volume overall is gonna go up at first, but it's only for 90 days. And so you're constantly having people turn past those 90 days and they're done as you're writing for new ones. And so it's a fluctuating group of people that you're managing, not necessarily an exploding program where all of a sudden you have to manage 500 people. Um, it won't probably ever reach that kind of size. So that's something to think about too when you talk about staffing or managing it moving forward. Um This is the published data behind uh A MS itself that uh Zole put out there as part of the B A trial. Um So this was presented at the American College of Cardiology Scientific Sessions. Um And then just recently published just last week, which will show on the next slide as well. Um But the important thing to take away from the study here uh just published last week in the journal of American College, American College of Cardiology was that they looked at about 522 people. Um They put the patch on everyone but they only monitored half of those people. Um And overall, it showed you about 38% relative risk reduction in 90 day, he heart failure rehospitalization. Um We've been working close with Zole and looking at different data that they show here regarding h vamps and successes with heart failure hospitalizations overall. Again, that 38% relative risk reduction that they've gotten from their data and then important in yellow is based on projections of local pilot data for every 100 HF MS that are placed. It's estimated a projected cost saving of one year of $430,000. And that's just with 100 H vamps. So that's pretty cool. I think that's the end. Let me make a few great job. Let me make three final statements and then we'll open up the floor to any comments or questions from anyone. I appreciate everyone attending. Um Number one early on because of our pre existing relationship with Zole from previous trials. When this opportunity came up, Chelsea came and said, look, this is something I think would be really exciting as a as an addition to what we're offering in our, in our beach oriented heart failure, sort of outpatient community program. And the follow up from Cardi seemed very similar. Um early on I approached doctor Hurry, uh who was kind enough to sort of give some thoughts, tips tricks and said, you know what a pilot, let's see what the data actually looks like that was prior to the publication of the B mad trial. And so we thought we'd unroll this as, as a local pilot. We have a really strong heart failure uh team at the beach. Um I've worked with them for many years. Uh They do a tremendous job of trying to monitor those patients as do the programs all across the system beach is unique because it's a, it's a hospital that has on site PC I and, and some, some of the higher end services, but at the same time has a population that tends not to want to drive across tunnels and stick locally. So it was a nice target population to look at and I promise doctor hurry and the tremendous A HF team that we kind of bring some of the data back. And that would let us maybe power some discussions across the system about what can we do better? The heart failure team doesn't credible job. But with the work on VADs transplants in that complex group, I think it really is incumbent on each of us in cardiology, every physician A PP to help, think about these patients and think what we can do to help and just like heart failure. That's true. Whether we're talking about structure heart and valve disease management, um the Coronary Disease chip program and management of General Coronary Disease and guideline driven medical therapy. It's true with lipids, it's true with arrhythmias and A FB. And so I'm proud of our team as a whole for cento cardiology. It's a lot of physicians, nurses, administrative teams, A PPS and too many people to really count who participate together in this team management of different disease processes. And this is one example. So that was number one, number two, I wanted to again, call out to all the people at beach that have been part of this um Chelsea's led, but there's been a lot of people who've been helping and making this program successful here and to at least send the team for administratively supporting and, and saying, let's look and see if this really does make sense for us. And then the third and final comment I have is across the practice. You know, you look at the stuff we've achieved. Uh We just had a party a couple of weekends ago to recognize our A PPS and to also recognize Ron Stein for the years, he served as chief and for the ongoing work he's doing and everything we have um the final week of A PPP A NP recognition and our teams are amazing. This is a project. Really Chelsea deserves tremendous credit from at the outset saying I'd like to try this and then from really ma managing it, she and many of our A PPS really working at the top of licensure are tremendous resources for taking care of patients across the gamut. And you've seen this with arrhythmia clinics we're generating with eul projects where both physicians A PPS nurses are participating in with um with so many different things. It's hard for me to talk in the short amount of time we have, but it makes me really proud of our team to see all the things we're doing across the spectrum. And Chelsea kudos on a great grand rounds. Talk. Yes. All right. We'll answer any questions. I'll take the easy ones and Chelsea will take the hard ones and Amy, I don't know if you're on the side. Thank you for the, the clapping hands. Um, Amy, I don't know if, if there's anything on the chat box, if you don't mind reading those for us and then I'm answering some text ones too. Uh Most of the text ones appear to be more comments than questions, but the comments we're getting are a great job. Chelsea, nice work. Kudos to beach team. I do not see any chat questions. All right, we'll give it a minute. Any other comments you want to add? No, I don't think so. I do think it's particularly interesting that, uh, you had three patients who said they were going to do it didn't actually wear it and all of them ended up back here again. Did anyone in that group end up doing it the second time around? No, they did not. Even if I was like standing outside their room waving, holding the H FS device, they just, they didn't want to take the bait. So it's all right. It's not for everybody but I love it. Well, I know it's, I know it's a busy week with Lisa Cupid and so forth. Anyone that wants to reach out with a question offline, please don't hesitate to, uh, to text or email or call us. Yeah. And I think just you know, individual hospitals. If you guys are thinking of how this could look, I think maybe it's just having a discussion amongst your team of primary people that are there and how you would want to have it. Look. Uh uh chat question from Lauren Feeney. I see there are strong data with the enrolled patients and their readmissions. Did the hospital readmission for CHF go down. Yes, Alisa is nodding. Yes. Again, remember this is a pretty small pilot, but that's impressive. It's, it's impacting the hospital as a whole. And you know, there's so many different projects we're continually based in. It's often hard to isolate a single um initiative and what it's doing. But it is neat to see in your close to 40 patients, we've seen a reduction across the hospital. Uh Let me read a couple more of these. Number one, this thing is similar slash identical to thoracic impedance but without an implanted device, unfortunately, thoracic impedance has not been shown to be effective in reducing readmissions, any thoughts or comments that's from Doctor Cleven. So, so let me start answers and Chelsea speak up, Tom. You're right. It's interesting if we think about some of the uh some of the um devices put in typically for management of arrhythmia. We've, we've been involved in a number of trials that have added, for example, a lead or monitoring of direct pressures. And we've also been involved in devices that try to utilize a I algorithms or even just clinical sort of metrics for looking at thoracic ps. Remember those devices really aren't dedicated to this one arena. And so you're right that the clinical trials and our own experiences have been a little bit hit or miss I still think value to that. But remember the, the focus during the device implant and, and some of our EPS might wanna speak up to this too, but the the focus is really getting the leads in place to achieve an arrhythmia effect. It's really a side effect uh altogether from measuring thoracic impedance. So perhaps it was implementation and the way we monitor those, perhaps it's the team and you know, having the ability to contact the patients and the monitoring to get us that information. But if you also compare the data we have from B MA, which is a small trial, it's 500 plus patients to some of the earlier data. The data looks more impressive. And so I don't know pathophysiology, why there would be a difference in that. But it seems like both the larger scale data and then our immediate on site data, which is admittedly very small. But it seems like that data suggests maybe um there is uh some benefit to this and I was just gonna add in too. I think when it comes to uh thoracic impedance, uh generally speaking, you're waiting on some lead maturation which takes some time once that's done. Um whereas this is something where, you know, you're putting this patch on and within a couple of days you're getting readings and tracking these people. So it's a little more of an immediate thing too. Um So we saw some important info there and two more questions, one is on the screen, it says are patients able to see their trends? That's a good question. They are not. Um Sometimes I don't even explain it as a number to patients because I feel like as soon as I mention a number, then sometimes they become fixated on what their number is and what they're trying to stick at. Um So I don't always explain it as a number. I'm telling them, I just am only going to call them if I get an alert or a change in their reading is sometimes how I phrase it. Um But I try to show away from telling people I'm keeping them in a number, especially because it, like I said, it's different from our Cardios program. Cardios. Everyone does have a certain P ad goal or different trend that's uh you know, individual to that patient this way, this H PM, it does not work that way. So even if I did share a number with everyone, it's supposed to be 1.0 right? So um I think to try to explain that to a patient. I don't know if they wanted to tune in for grand rounds for me to explain that in this sense. So um no, I did not share a reading or a number with anyone and one comment I would before we get to the next question is with cardamoms. That's been a long discussion, a long bit of discussion. Do we show patients their data? I personally am an advocate of that and although it doesn't exist, what I would love to see us do with some of these things is have, is have kind of a uh iphone red green, yellow light report to the patient. So maybe the numbers too much, but they could see that they're in the green. That wouldn't be great for every patient. But I think some patients would love that reassurance early on. You know, the advanced heart for your team has done a lot of this as well. Any of us who've had some experience with implanting and then monitoring cardios, we'll tell you the, the patients run the gamut. There's some patients who seemed so interested and excited about it and then they only do a reading once every two months. And on the other hand, there's patients at the beginning, especially before we set expectations who kind of want someone to call them every day with an update on the number. And we had to break that expectation early because that, that's impossible. We had to teach them. Just wait, if you get a call, if you're not getting a call, it's all good news. Two more questions. Uh one uh online and then one on the phone, let me do the phone one quickly. First. Uh the question on the phone I got was did hospital length of stay change with heart failure monitoring, for example, were any patients dis discharged home sooner? Um No, but I will say we've had discussion of how do we grow this program or change our protocol? I guess moving forward. And we've been thinking um there's some, there's some speed bumps to this process. So I I'll admit that before saying it. But if we can get an HF MS identified in order for the right patient, also send them home with a Fosi script. Um and then track them that way, then where our thought was, you might be able to get that patient out the door a little sooner if you can send them home where they have access to maybe one more dose of IV Lasix at home, not IV N and the sub Q through fosi. Um But that way we might be able to shorten some length of stay. Um But there's a couple of dominoes that have to fall into that place right now fo six, it takes a little bit of extra leg work to get that approved, extra paperwork and whatnot. So, um we're not there quite yet. Um But I would say that's kind of the next pivot we've discussed is how to focus, this takes care of some readmission data. How can we focus on uh length of stay? So great question. And then there are two questions on the in the chat box that are actually very similar to each other. So I'm going to combine them together. The first from Lauren says with so many remote monitoring programs available and patients enrolled if you count, for example, heart logic, cardios and now add H vamps to it. What is Centa doing for infrastructure and support? And it Lisa asked a similar question which is great pilot, great work, Chelsea. What does growth of the program look like moving forward? Let me let you answer in the next. Well, I think like I mentioned is it, it's an, it's an easy thing to discuss in the beginning here, right? To tell you about each fan show you how it works. It seems awesome. The back end is what do you do with all this data? And it's just me managing all of it. Um So I think that's part of the ongoing discussion that I hope you guys will have amongst your teams today at your primary locations. Is if you were to consider starting this, what does it look like for you guys? Is it one A PP that has to be willing and interested in doing this? I would not force this on anyone. Um But is there one A PP that's interested in managing and becoming that ordering provider that can manage this. Do you identify a couple A PPS? Right. If we're talking about a bigger hospital system, um, where a couple people have the ability to order and track those people, but then you're individually taking the responsibility for those, um, HF MS that you order. So I think it could look different depending on each hospital system and what the team wants it to look like. Do you have a fantastic nurse in your outpatient setting that you wanna have someone order this in the hospital and then have the nurse, um you know, be able to log in and track those readings. Um It, it has the ability to look a little different at each place depending on how you wanna manage it, so you can kind of personalize it. Um I guess to that extent, my comments on top of that are these are great questions and I think this is this has been an ongoing discussion and this adds one more piece to the puzzle of what we think about. I think there are multiple different ways we can be successful in this and, and so we need to engage in this. Some quick thoughts I have from limited experience to date is as we grow sites as we have a number of sites. There are two always competing thoughts about how to do this. One way is to centralize and have one center managing everything. The other way is to have successful programs at different locations and have each working harnessing its strengths. And there are pros and cons to each my observation having participated in. This is one of the successes of the way this is done is the the the more knowledge of the individual patient that the person who's monitoring the data has sometimes the more effective. That is for instance, a patient who knows Chelsea has seen her for four days in the hospital, maybe it followed with her for years in the office or with our team is, is someone who we know, you know, their intricacy. Sometimes we know what things they eat, what they wanna do. Cardiom. It's interesting. One of our first patients, what we discovered and it was an expensive way to discover it is that their wife's uh eggplant parmesan was what always put them in heart failure, three separate episodes. Um We couldn't figure it out during hospitalizations because it was hard to tag it to what was happening. But it was like a 345 day gap and they'd come in with heart with cardamoms. It was amazing. We could plot the date. It was a beautiful curve that really showed what was going on and educated them. That's the kind of thing that helps to have some direct interaction and knowledge with the patient. But the problem with that is none of us is working, you know, 24 73 65. So we have to build redundancy and teams to support the economics are an important part of this as well. And this pilot has us a little bit of a way to look at some of those economics. They're always contingent on off scale effects like reducing hospitalization or length of stay changes in medication, that kind of thing. Um So that's the toughest question. I don't have a final answer. I think this is another reason for us to sit down and figure out what are we looking for system wide? And many of you that are asking that question have already been part of those discussions and we have to keep those discussions going that this is this isn't something brand new in that realm. One more question, you might have already mentioned this one, but there was one thought is centered at home virtual program. Um Yeah, I mean, that's a thought too is to involve the program like that. Again, it would just have to be how you delegate the ordering provider and then who, you know, is there a provider there that's willing to take on managing this data. Um So that's a great thought as well. Um You know, that just throwing out ideas for how to make this look, um you know, system wide or at each place individually. So, yeah, great thought. And to me, it's kind of interesting you think about this, this is a data stream that comes to you that you can't turn off. You have to pay attention and you hate to miss, you know, five days of a message that would have prevented an event because we weren't available. And so whether it's data like in uh those live monitors for arrhythmias, whether it's something like this in the heart failure realm, we do have to have an ability to respond. And so these are, these are such great questions and these are things that, you know, when I get an alert, I call the patient that day. You know, um that's part of the reason I was managing it myself is that, you know, we have fantastic staff. Um sometimes you send a message and they get a million messages a day. And so my message is sitting in that in basket saying, hey, can you please call this patient? You know, their HP M's reading is up or something like that. And so, um I took this on, on my own so I could reach out to the patient directly because I don't, I wanna act on that elevated reading that day instead of risking their readmission tomorrow, you know. All right, two more questions. The top one there, if you can scroll up just a bit was, can this be used in New York Heart Association class four patients for Carly? Yeah, absolutely. Remember just your big exclusions there, you know, you wanna put it on a patient who's dry because of what it takes those baseline readings and you cannot put it on a patient who's about to start dialysis within the, within the next 90 days. And then anyone that already has a device in that can monitor their fluid. So, CardioMEMS, um C RT D uh any sort of LVAD, something like that. But otherwise, yes, it doesn't necessarily dictate what class of heart failure they are. Yes, they can have it. And the only disclaimer I'd add to that, which, which is obvious to this group, but is remember, this is for symptomatic management of heart failure. The key for those patients is also to make sure they're on very guideline driven medical therapy and to early on involve the heart advanced heart failure team because those are patients that often, you know, could, could go on to more advanced therapies that could be life changing in effect, more morbidity and mortality. One more question. Do you see this as an opportunity to support expanding our heart fair clinic coverage? Currently, appointment availability is really difficult to obtain. Great question. Yeah. Yep. So would absolutely love to expand heart fair clinic coverage. Um We're at least here out of the beach, we're limited in terms of physical office space. Um Our office out here is pretty tight and we don't have the space, the exam rooms to add another provider there. Um So aside from space, then it also comes down to provider constraints. We actually have um a provider that can staff it um would love to explore that more. And we've been having those discussions about trying to break out something like that within the beach office. But then again, it kind of raises the question of, are you able to start a program individually in each clinic and who manages that? And you know, do A PPS rotate through that? I mean, we used to have a HF come out to our beach office once a week and I know um with some changes recently, uh we don't have them as much in our office anymore. And so I think we are kind of try, we trying to scramble a little bit to fill that gap and be able to reach these patients um before they're, you know, in a worse off way. So, absolutely. And, and to maybe highlight that point, Chelsea, what I would say is this our advanced heart failure team is spread thin but does an incredible job. A part of what we're hoping is to make sure they see the toughest patients that they can benefit the most. So potentially two options are one to use this to extend the capacities of the advanced heart failure team if, if there's interest there. And again that a lot of discussions ongoing already in that realm. And this is maybe one more thing looking at this data to see if this has a role. And then secondarily in order to really make sure we have that second tier of care available to patients for those patients that really aren't at the level, they necessarily need to, to be pushed into an advanced heart failure doc schedule our A PP, nursing and general physician coverage can help a lot of those patients prevent readmissions and so forth. And so that's the second group, this is potentially useful for. So both both levels of care, both the advanced care from the advanced heart failure team and the community level care from the general cardiology teams. This has potential implications for I know we're heading towards the end of our time. This has been a great discussion and uh Chelsea Kudos to you and the team and I would say this is a groups together and, and use this to, to sort of be one bridge in conversations that are already ongoing. Thanks everyone for attending and grand rounds will be again next week and again, we'll send out invites for all the conference information that um that for those that missed it. Thanks everybody.
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